Annuity Information Request Form

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Step 1 of 6

Personal information

Let's start with the basics.

Full legal name

Please enter your full legal name.

Date of birth

Please enter your date of birth.

Mailing address

Please enter your mailing address.

City

Required.

State

Required.

ZIP code

Required.

Phone number

Please enter a phone number.

Email address

Please enter a valid email address.

Marital status

Please select an option.

U.S. citizen?

Please select an option.

Step 2 of 6

Spouse or co-applicant

Only fill this in if a spouse or co-applicant will be included on the annuity. Otherwise, skip ahead.

Full legal name (optional)

Date of birth (optional)

Phone number (optional)

Email address (optional)

Step 3 of 6

Financial snapshot

General figures are fine — this helps us understand fit, not qualify you for anything.

Current employment status

Please select an option.

Expected / current retirement age

Please enter an age.

Approx. total investable assets

Please select a range.

Approx. annual household income

Please select a range.

Existing guaranteed income sources (Social Security, pension, etc.)

Step 4 of 6

Existing annuity or retirement contracts

Do you currently own an annuity?

Yes, I currently own one No, I do not

Purpose of this inquiry

Please select an option.

Step 5 of 6

Goals and risk tolerance

What are you hoping this annuity will do? (Select all that apply)

Guaranteed lifetime income Principal protection Growth potential Legacy / death benefit for heirs Long-term care coverage Tax-deferred growth

Amount you're considering placing into an annuity

Source of funds

When would you like income to begin?

How long can these funds stay invested before you need them?

Risk tolerance

Conservative — protect principal Moderate — some growth, limited downside Growth-oriented

Step 6 of 6

Beneficiaries & final notes

Primary beneficiary name

Relationship

% share

Contingent beneficiary name (optional)

Relationship (optional)

% share (optional)

Additional notes or questions (optional)

I authorize this information to be used to research and present annuity options on my behalf. I understand this form is not an application or purchase of any product.

✓

Request received

Thank you — your information has been submitted. Someone will follow up shortly to discuss options that fit what you told us.

Your information is used only to research annuity options on your behalf and is not shared with third parties without your consent. See our privacy policy.